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Minimally Invasive Breast Surgery
Joint Hospital Grand Round
Luk Wai Yin Sally
British Medical Journal
• Minimally invasive surgery for breast cancer
– May be trading better cosmetic outcomes for worse
rates of cure
– Monica Morrow
BMJ Feb 2009 338: b557
Minimally invasive surgery for
breast cancer
• Why ?
• What ?
• How?
Why minimally invasive?
• Breast Cancer
– Prevalence
• Most common female cancer in HK
• Cumulative life risk 1/22
– Screening
• Worldwide, women aged > 40 1
• Allow detection of small/early breast cancer
• Medical advancement
– Better understanding of the pathophysiology and the necessity
of local control of breast CA with its risk of local recurrence
– Neoadjuvant/ adjuvant treatment
– Improvement in surgical techniques and instruments
• Patient demand
What is it?
• No definition
– Breast conserving surgery, sentinal lymph node bx
– Oncoplastic breast surgery
– Endoscopic breast surgery& axillary surgery
• Goals:
Oncological clearance
Aesthetic outcome
How to achieve?
Breast Surgery
Modified Radical Mastectomy
Breast Conserving Therapy
Oncoplastic Breast Surgery
Endoscopic assisted breast
Axillary Surgery
Level II axillary dissection
Sentinel lymph node biopsy
Endoscopic SLNB/ AD
Breast Conserving Therapy
• Wide local excision (WLE) with postoperative adjuvant
• Oncological principle for WLE:
– Relative risk of local recurrence was shown to be directly
related to completeness of excision
– Local recurrence direct impact on long-term survival
– Aim: ideally a clear rim of normal tissue around the carcinoma
in all direction
– at least microscopically disease-free margin
• In practice, 1cm macroscopic margin of normal tissue
1 NIH Consensus Conference Treatment of early stage breast cancerJAMA 1991:265:391-5
Breast Conversing Surgery
• Equivalent outcome to that of mastectomy in early breast cancer
– Effect of radiotherapy and surgery in early bresat cancer: an overview of the randomize
trial; Early Breast Cancer Trialists’ Collaborative Group N Engl J Med 1995;333:1444-55
– Breast conserving therapy versus mastectomy in early stage breast cancer: a metaanalysis
of 10 year survival; Morris etal Cancer J sci Am 1997;3:6-12
• Long term Oncological safety
– Twenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy and
lumpectomy plus irradiation of the treatment of invasive breast cancer
Fisher B et al N Eng J med 2002;347:1233 -41
– Twenty-year follow-up of a randomized study comparing breast-conserving surgery with
radical mastectomy for early breast cancer Veronesi U et al N Eng J med 2002; 347:1227
• Better cosmetic appearance in majority of women
– Cosmetic assessment of breast-conserving surgery for primary breast cancer.
Sharif K et al Breast 1999;8:162-8 review of level II evidence
• Lower levels of psychological morbidity with improved body
image, sexuality and self-esteem, compare to mastectomy
– Comparison of psychological aspects and patient satisfaction following breast conserving
surgery, simple mastectomy and breast reconstruction
Al-Ghazal SK et al. Eur J Cancer 2000;36:1938-43
Comestic failure after BCT
• 23 - 50% dissatified with the appearance after BCT
• A body image scale for us with cancer patient Hopwood P Eur J
Cancer 2001:37:189 -97
• Cosmetic evaluation of breast conserving treatment for mammary
cancer Van limbergen E Radiother Oncol 1989;16:159-67
• Factors affecting comestic outcome
Volume loss >20%1
Tumor location: central, medial, inferior
Nipple areola displacement/ distortion
Inappropriate incision/poor surgical technique
Effect of Radiotherapy
Cosmesis and satisfaction after BCS correlates to the precentage of breast
volume excised Cochrane R et al. Br J Surg 2003 90:1505-1509
Oncoplastic Breast Surgery (OBS)
Seamless joining of extirpative and reconstructive breast
surgery performed by a single surgeon 1
Thorough tumor resection plus reconstruction of resection
Principle of OBS
Oncological principle of resection to achieve wide tumor-free
ii) Principle of plastic reconstruction to optimize cosmetic
outcomes and minimize complication
1 Oncoplastic breast surgery: A Global Perspective on Practice, Availability, and training
Peter L Malycha et al; World J Surg 2008 32:2570 -2577
Reconstruction Principle
• Volume displacement
Recruiting and transposing
local dermoglandular flaps
into the resection site
– breast-flap advancement
– Mammaplasty
• Superior pedicle
• inferior pedicle
– Centralization of NAC
– +/- Contralateral surgery
(reduction mammoplasty)
• Volume replacement
Importing volume from
elsewhere to replace the
amount of tissue resected
– Autologous
• LD flap
• TRAM flap
– Implants
Reconstruction Principle
• Volume displacement
• Volume replacement
– Autologous
Picture adopted from Surgical insight: oncoplastic breast-conserving reconstruction; Rainsbury;
Factors influencing technique chosen
Volume displacement
Volume replacement
Breast size
Medium or large
Small or medium
Tumor position
Central or lower pole
Any site
Bilateral breast
Breast + back
Theater time
2-3 hr
Flap ischaemia
Fat necrosis
Donor site morbidity
Flap loss
Mastopexy lumpectomy
• Proponent
• Opponent
– Potential oncological benefit to
enable very wide excision of
breast tissue without risking
major local deformity1,2
– Extend the scope of BCS to
include patients with 3-5 cm
tumors, without compromising
the adequacy of resection or
the cosmetic outcome
– Overall better cosmetic
1 Oncoplastic techniques allow extensive resections for
BCT of Breast cancinoma
Krishna B Clough at el. Ann Surg 2003 Jan;237(1)26-34
2 Lumpectomy ws oncoplastic surgery for BCT of cancer.
A prospective study of 99 patient
Ann Chir 2006 Apr:131(4):256-61.
– Oncological safety of the
techniques is not being
evaluated properly
– Potential cosmetic failure and
– Extra resources and extended
operation time
– Negative impact on the
adjuvant treatment
Any clinical evidence ?
Evaluation of oncological safety
cosmetic outcome
Potential complications/pitfall
Review of outcomes of OBS
No of studies
displacement replacement
Total no of patient
Median follow-up (m)
Local recurrence(%)
Cosmetic failure (%)
Review: Oncoplastic breast-conserving reconstruction – indication,benefits,choices and outcomes
(from 1 Jan 1980 to 31Jan 2007) Rainsbury Nat clinical pract onoclogy Nov 2007 4:11657-664
Study design: case-control cohort studies from Sept 1994- December 1999
No of subject: 148 (10-108)
Median follow up: 74 months
Oncoplastic procedure:
volume displacement for small defect and volume replacement for large defect
Concomitant contralateral breast mammaplasty
Local recurrence: 3%; distant metastasis 13%; Mortality 7.53%
Conclusions: Long term oncological outcomes are comparable with result of BCT in RCT
• emerging level II evidence for the short
time oncological safety for OBS with good
cosmetic outcomes
• Published guideline
Oncoplastic breast surgery – A guide to good
Association of breast surgery at BASO;
Association of breast surgery at BQPRAS and the
training Interface group in Breast Surgery
Royal college of Surgeons EJSO 33(2007) S1-S23
Endoscopic Breast Reconstruction?
Endoscopic Breast Surgery?
Endoscopic breast reconstruction
• Endoscopic assisted techniques
– Harvest more bulky myosubcutaneous flap
• BassLS et al Endoscopic harvest of the rectus abdominus free flap An Plast
Surg 1995:34:274-9
– Endoscopic dissection
• Endoscopic techniques in aesthetic breast Surgery Clin Plast Surg
– Balloon dissection technique
• Van Buskark Er et al. Endoscopic harvest of the lastissimus doris muscle
using balloon dissection technique Plast Reconstr Surg 1997:99:899-903
• Laparoscopic mobilization of greater omentum for breast
– NICE guideline support its use under normal clinical arrangement
Oct 2007
Laparoscopic mobilization of greater
omentum for breast reconstruction
Endoscopic Breast Surgery
• NICE overview for endoscopic mastectomy and wide
local excision for breast cancer NHS April 2009
– One non randomize trial
– eight case series (mainly from Japan and Korea)
– Total no of patients: 809
• Conclusion:
– Current evidence on the safety and efficacy of endoscopic
mastectomy and wide local excision for breast cancer is
inadequate in quantity
– Only used in the context of research
• The goals of minimally invasive surgery for
breast cancer is to improve aesthetic outcome
without comprising oncological clearance
• The early results suggest Oncoplastic breast
surgery has a promising future in management
of breast cancer
• Anticipated maturation of endoscopic technique
in assisting breast reconstruction and breast
• We should try out BEST to treat our patient’s BREAST
Thank You